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Patients and methods A case–control study was carried out on a sample of Egyptian women using a self-filled questionnaire. A group of 60 obese women (BMI<30 kg/cm2) and a matching group of 30 nonobese women (controls) participated in this study. They answered a questionnaire that included 20 questions covering four domains (demographic data, assessment of female sexual function, weight image variables, and verbal or physical abuse by husbands). All women were free from diseases known to affect sexual function.

Results Nonsignificant differences were found between obese and nonobese women in terms of arousal, ability to reach orgasm, and occurrence of unprovoked desire to have sex. The most preferred coital positions were rear entry in the obese group and man on top in the lean group. The practice of oral and anal sex was uncommon for both groups. Satisfaction with sexual life was significantly higher in the nonobese group. There was a statistical correlation between weight loss and improvement in libido. Three quarters of obese women reported being verbally abused by their husbands because of their body shape.

Conclusion There is a tendency for obese women to be inferior to their lean counterparts in many aspects of sexual functioning. Weight loss seems to be useful in boosting libido in obese women.

Obesity is increasing in prevalence at a rapid rate worldwide. The WHO formerly recognized an obesity epidemic in 1997 1. A fact sheet issued by the WHO in 2013 indicates that, worldwide, obesity has almost doubled since 1980 and that in 2008, more than 1.4 billion adults, 20 years and older, were overweight (BMI≥25 kg/m2). Of these, over 200 million men and nearly 300 million women were obese (BMI≥30 kg/m2) 2.

Although few developing countries have nationally representative longitudinal data to assess trends, global estimates using both longitudinal and cross-sectional data indicate that the prevalence of obesity in countries in intermediate development has increased from 30 to 100% over the past decade 3.

Obesity among adults, particularly women, has reached very high proportions in Egypt. According to the WHO, 46% of adult women in Egypt are obese 4.

Obesity has been reported to be among the factors that adversely affect the sexual health of men and cause erectile dysfunction. For instance, the 9-year follow-up Massachusetts Male Aging Study 5 and the 25-year follow-up Rancho Bernardo Study 6 reported that body weight was an independent risk factor for erectile dysfunction, with a risk exceeding 90% of controls. However, the effects of obesity on female sexuality have not been clearly defined 7.

There is considerable research on obesity and on sexuality as separate issues. The lack of research by sexologists or by obesity experts on the interrelation of the two subjects appears to indicate that researchers do not believe that sexuality and obesity can coexist 8.

The present study was carried out to examine the effect of obesity on female sexuality in a sample of obese Egyptian women compared with a matching group of nonobese women.

Patients and methods

The current study included 60 obese women and 30 matching nonobese women as a control group. The definition of obesity used was that suggested by the WHO 9, where an individual with a BMI of 30 kg/m2 or greater is considered obese. Obesity is further classified according to its degree as follows: class I 30.00–34.99 kg/cm2, class II 35.00–39.99 kg/cm2, and class III≥40.00 kg/cm2.

For a woman to be included in the study, she had to be sexually active (living with her husband for the past 6 months) and also able, at least, to read and write in order to fill the questionnaire used in the study.

Women affected by diseases known to affect sexual functioning (e.g. renal or hepatic failure or severe osteoarthritis) were excluded. Women older than 55 years of age were not included to avoid the effect that age may have on sexuality.

After obtaining their consent, women were asked to answer the questions listed in the questionnaire. Each participant filled her copy of the questionnaire, left it anonymous as instructed, placed it in an envelope, and sealed it personally.

The instrument used was a self-filling questionnaire designed by the investigators. Some of the items were selected from the female sexual function index (FSFI) 10. Some questions were added to obtain information related to obesity.

The questionnaire included 20 questions covering four domains:

Demographic data: age, educational level, and weight and height to measure the BMI.

Statistical analysis

The data collected were tabulated and analyzed using SPSS, version 16 software (SPSS Inc., Chicago, Illinois, USA). Categorical data were presented as numbers and percentages. The χ2-test was used as a test of significance. P<0.05 was considered significant.

We obtained the approval of the Ethics Committee of Banha Faculty of Medicine before starting the work.

Female sexual functioning

Coital frequency

The most frequent coital frequency in the entire sample was once per week (34.4%), followed by 2–3 times/week (25.6%). In general, coital frequency was higher in the obese group, with a statistically significant difference (P=0.004), as shown in Table 2.

Coital arousal (engorgement of sex organs and vaginal lubrication)

More women in the obese group were unable to achieve arousal during intercourse (28.3 vs. 26.7%). Comparison of the ability to achieve coital arousal in both groups showed no statistically significant differences (Table 3).

Ability to reach orgasm

When asked about their ability to reach orgasm, the responses of ‘Always’ or ‘In at least half of their sexual encounters’ were provided by 61.7% of the obese women, whereas these responses were provided by 53.4% of nonobese women. However, the difference was not significant (Table 4).

Frequency of occurrence of unprovoked desire to have sex

Preferred coital position

Rear entry coital position was the most preferred position in the obese group (35%), especially those of class II (47.4%). However, man on top was the most preferred position in the nonobese group (43.3%). There was no statistically significant difference between both groups or between the three subclasses of the obese group (Tables 6 and 7).

Practice of fellatio, cunnilingus, and anal sex

There were no significant differences between the two groups in terms of practice of oral and anal sex. Fellatio was practiced by 11.6% of women in the obese group versus 6.7% of the women in the nonobese group. In the obese group, 8.3% of women received oral-genital stimulation, whereas 3.3% of husbands of the women in the nonobese group practiced cunnilingus. No obese woman reported the practice of anal sex, whereas 3.3% of nonobese women engaged in anal sex.

Satisfaction with sexual life

A statistically significant difference (P<0.025), in favor of nonobese participants, was found between the two groups in terms of satisfaction with sexual life. 58.3% of the women in the obese group were dissatisfied with their sexual life in contrast to only 6.7% in the nonobese group (Table 8).

Weight issues

Subjective evaluation of sexual appeal

When asked: ‘Do you think your body is sexually appealing’, 46.7% of the women in the nonobese group responded with ‘extremely’ or ‘quite’. In the obese group, this answer was given by 41.6% of women. When stratified by degree of obesity, this answer was given by 50% of class III women (morbid obesity). The difference was highly statistically significant (Table 9).

Weight loss and libido

Most obese women (46.7%) reported an increase in libido following weight loss but 41.7% of them felt no effect. Increased libido following weight loss was most evident in women with class II obesity (63.2%). There was a highly statistical negative correlation between weight loss and its effect on libido (Table 10).

Husband’s attitude

Verbal abuse by husband because of body shape

Three quarters of obese women reported being verbally abused by their husbands because of their body shape. This percentage was 36.7% in the nonobese group, with a highly statistically difference (Table 11).

Discussion

The fact that 44.4% of our participants had a university degree lends credibility to the results obtained. However, education level affects sexual behavior positively and this may limit generalization of our results.

Studies comparing sexual function in women with a large body mass with their lean counterparts provide conflicting results. Coital frequency is a good example; Speakman et al. 11 reported a significant negative correlation between hip and waist size and coital frequency. However, a study carried out on 6690 women between the ages of 15 and 44 years by Kaneshiro et al. 12 found a statistically significantly higher likelihood of ever having intercourse in obese women compared with normal-weight ones (77 and 56%, respectively). This is similar to our results. Kaneshiro et al. 12 explained their unexpected results by stating that ‘Obese and overweight women do not report decreased frequency of sexual encounters as compared with their lean counterparts’. This may also hold true for our results. Besides, in Egypt, where obesity is common, abstaining from having sex with a fat spouse is a luxury that many people cannot afford!

Obesity seemed to have no effect on arousal, ability to reach orgasm, or libido in women as the figures for both groups were very similar, with no statistically significant differences. Smith et al.13, after studying 8656 obese and nonobese men and women, concluded that there is little association between BMI and self-reported sexual difficulties (low libido, difficult lubrication, and inability to reach orgasm for women). However, Kirchengast et al.14 reported that body weight and BMI were significantly related to the degree of reduced sexual interest, but their participants were all postmenopausal women. Esposito et al.15 concluded that obesity affects arousal, satisfaction, and orgasm, but not desire and pain. However, all their participants had sexual dysfunction.

Although our obese participants preferred rear entry (35%) as a coital position, the lean ones preferred the man on top position (43.3%). We assume that these preferences can be attributed to ‘mechanical’ causes because when this preference was stratified by the degree of obesity (Table 7), women with class I obesity preferred the man on top position, whereas women with classes II and III obesity (more obese participants) preferred the rear entry position. In a study 8 on 478 obese women, the rear entry coital position was the second most preferred position by obese women and their partners (18.2%); the most preferred position was man on top (20.1%). However, the degree of obesity was not reported. Positional difficulties during coitus affect morbidly obese patients. One study 16 conducted interviews with 82 morbidly obese women (mean BMI, 42.8 kg/m2); 11% cited ‘physical problems’ as the foremost difficulty when engaging in sexual intercourse.

Although no significant difference was found between our two groups in the preference to practice and receive oral sex, there was a trend for obese women to prefer this action more than nonobese women, with almost double percentages in favor of the obese group. If taken as a whole, 16.7% of our participants practiced oral sex in coitus. This is relatively low compared with USA, where 66% of women practiced oral sex in 2010, increasing from 42% in 2007 17. In Britain, the percentage was 56.6% in the 1990s 18.

None of the obese participants reported the practice of anal sex, whereas 10% of the women in the nonobese group engaged in anal sex (i.e. the affirmative response for the entire sample was 3.3%). National survey data from the United States and Great Britain indicate that the percentage of men and women who engage in heterosexual anal and oral sex has increased since the early 1990s 19,20. An American study 21 found that 30% of women and 34% of men had ever engaged in anal sex. However, 75% of men and women reported ever receiving or practicing oral sex. In the UK 18, the prevalence of anal sex was 6.9% for men and for women 6.1%. The discrepancy between our results and those in the USA, in terms of oral and anal sex, may be because of the conservative nature of the Egyptian society and the religious prohibition of anal sex. With widespread access to internet porn to young Egyptian generations, it can be speculated whether the prevalence will increase in the near future.

The prevalence of heterosexual anal and oral sex is important because the behaviors are associated with negative sexual health outcomes. Heterosexual anal sex has been identified as a risk factor for HIV infection and other STDs (e.g. human papillomavirus infection) 22 and anal cancer in women 23.

In terms of the degree of satisfaction with sexual life, there was much more dissatisfaction among the obese women compared with nonobese women (58.3 vs. 6.7%) (Table 8). This is plausible as Table 9 shows that 28.3% of obese women believed that their bodies were not sexually appealing at all (vs. 6.7% in the lean group) and also 75% of obese women were verbally abused by their husbands for their body shape (Table 11). Approximately 50% of the obese women studied by Arenton 8 were verbally abused.

When asked about satisfaction with sexual life, 34.5% of women in Arenton’s study 8 responded with: ‘Not at all’. Østbye et al.24 analyzed questionnaires completed by 91 men and 134 women before they enrolled in a weight reduction programme. The authors concluded that obese men and women report significantly less satisfaction with their sex life than the general population. Also, a study carried out by Yaylali et al.25 found a significant negative correlation between BMI and sexual satisfaction.

Among class II obese women (BMI=35–39.9 kg/cm2), 63.2% of participants reported that their libido increased with weight loss. Stuart and Jacobson 26 received 9000 responses to a questionnaire on weight and sex. Their conclusion was that 60% of women reported greater sexual desire and less sexual inhibition when they felt better about their bodies. In the current study, there was a highly statistical correlation between weight loss and libido. This was also reported by Hernández et al.27, who found that female sexual dysfunctions improved significantly 6 months after biliopancreatic diversion surgery to treat obesity. However, Huang et al.28 examined the effect of weight reduction in 338 sexually dysfunctional women with urinary incontinence. They reported no significant improvement in sexual function in overweight and obese women versus controls after an intensive 6-month behavioral weight reduction intervention. They suggested that amelioration of comorbid factors such as depressive or menopausal symptoms may be as or even more important in improving sexual function in this population.

Conclusion

There is a tendency for obese women to be inferior to their lean counterparts in terms of occurrence of arousal, ability to reach orgasm, and occurrence of unprovoked desire to have sex. Obese women preferred the rear entry coital position, apparently for mechanical reasons. The practice of oral and anal sex was relatively low in the entire sample. A marked difference, in favor of nonobese participants, was found between the two groups in terms of satisfaction with sexual life. Also, a significant proportion of obese women were verbally abused by their husbands for their body shape.